Making a provisional formulation

Two questions about the family arise from the above interview.

1. How does the family typically function?

2. Are there any family features relevant to the patient's problems? How does the family function?

A schema to organize ideas about family functioning builds from simple to complex observations: structure, changes, relationships, interaction, and the way in which the family works as a whole.

• The family tree will reveal the many family structures possible—single-parented, divorced, remarried, sibships with large age gaps, adoptees. Unusual configurations invite conjecture about inherent difficulties.

• Data will be obtained about notable family changes and events; the timing of predictable transitions is pertinent. Have external events coincided with these transitions (times at which the family may be more vulnerable)? How has the family met such changes?

• Relationships refer to how members interact with one another. What is the degree of closeness and emotional quality (e.g. warm, tense, rivalrous, hostile)?

Major conflicts may be noted, as may overly intense relationships.

• Particular interactional patterns may become apparent, which go beyond pairs. Triadic relationships are more revealing about how a family functions overall. A third person is often integral to defining the relationship between another pair. A conflict, for instance, may be rerouted through the third person, preventing any direct resolution. A child may act in coalition with one parent against the other or with a grandparent against a parent.

• At a higher level of abstraction, the clinician notes how the family works as a whole. Particular patterns (possibly a series of triads) may emerge that may have recurred across generations. For example, mothers and eldest sons have fused relationships, with fathers excluded, while daughters and mothers-in-law are in conflict.

Idiosyncratic shared beliefs may be discerned, explaining much of the way the family does things. 'Rules' governing members' behaviour towards one another or to the outside world may flow from these beliefs. For example, a family may hold that 'you can only trust your own family; the outside world is always hostile' they may therefore avoid conflict at any cost, and prohibit seeking external support.

Evidence of family difficulties may be found at each of these five levels. If they are, the question arises whether these do or do not relate to the patient's problems. Are family factors involved in the patient's problems?

Links between family functioning and the patient's problems take various forms, but the following categories cover most clinical situations: the family as reactive, the family as a resource, and the family in problem maintenance. Often, more than one will apply.

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